Natural History of Degenerative Cuff Tear-Decision Making-Dr A.N. Misra

Dr A.N. Misra
MS(Orth), MCh(Orth) U.K., FRCS (Edinburgh)
Shoulder & Knee Surgeon
Indraprastha Apollo & Apollo Hospital Noida
www.skishoulderknee.com

- Epidemiology
- Etiopathology
- Progression
- Healing
Do they heal
Factors that could help healing & better
outcomes
Implications on Treatment

Approx 85% - Type 1
Collagen
With increasing age –
more of Type 3

Harryman et al, JBJS 1991
Gohlke et al, Acta Orthop
2005
Microstructure at insertion
– 5 layers
Varied fibre orientations
Significant shear forces
Lamellar tears

Midsubstance – Type 1
Insertion site (compressive
loads) – Type 2
Repair – Type 3
(Disorganised scar
tissue)
Tears – Smooth muscle
actin cells (cause
retraction)

- Muscle atrophy
- Fatty Infiltration
- Tendon Retraction – SMA cells
- Increased Tendon Stiffness – Type 3 collagen
- Apoptosis – Programmed cell death

Increasing strain upto
60 degrees of abduction
Equal tension on both
sides
Stress concentration on
the critical zone
Mehta et al JBJS 2003

Fealy, Am J of Sports Med, 2006
Rudzski, JSES, 2008
Most blood flow- bursal pertitendinous, medial
cuff
Anchor site – least flow
Vascular response decreased with
age
time since repair
Exercise increased blood flow

Goodmurphy JSES, 2003 (Immunohistochemical
staining)
Greatest viability 2.5 -5mm from the margin
Matthews JBJS(Br), 2007
Cell activity & perfusion decreased at margins
and in larger tears

DECREASE WITH
- Age
- At the margins vis a vis a cm medial
- Tear size

Watershed areas
Increasing Age
Increase in type 3
collagen, GAGs,
apoptosis

Yamaguchi JBJS 2006 (588 pts, Ultrasound)
Average age 48.7 – no tear, 58.7 – unilateral, 67.8 –
bilateral
Almost half of the pts above 66 yrs have B/L tears
B/L sym tears – significantly larger
Sym tears occur in a 30% elder population vs asym
If sym tear on one side – 35% chance of asym on
other
Tears do not heal spontaneously

Maman JBJS 2009 (MRI Follow ups)
48% progress in size over 18 months
Full thickness progress more
Elder (>60 yrs) progress more
Fatty infiltration found with progression

Increase with time
Become symptomatic as size increases
Age strongly corerelates with tear size
Fatty infiltration correlates with tear size
No spontaneous healing

Matsen et al ,JBJS 1995 (Open Repair)
65% healing rates
80% healing of supraspinatus
32% healing of large tears
Age related
Ken Yamaguchi, JBJS 2004 (Ascopic Repair,
massive tears)
6% healing rates
Majority did well despite lack of healing!!

Focus on:
Surgeon – skilled/unskilled
Operation – Ascopic/open
Construct – Double/Single
Biology
Rehab Protocol
Environmental – Smoking, NSAIDs

Fealy, Warren et al, AJSM 2006
50%- Ultrasound
Sugaya, Arthroscopy, 2005
40% - Graded MRIs
Gerber et al, JBJS 2006
87% - One tendon – MRI
58%- Two tendon

Flatow et al JSES,
2006
Comparable results
for small tears
Larger than 3cm –
open did better

Sugaya et al, Arthroscopy 2005
Single vs Double Row
Significant improvement in structural outcome
Ken Yamaguchi et al
Double Row Healing Rates
67% - one tendon
36% - two tendons vs 6% in previous study
Bridged the gap by fixation strength & cons
rehab

Ken Yamaguchi et
al, JBJS 2006
88% healing rates
Age a determining
factor

Galatz, Thomopoulos, JBJS 2006
Nicotine delays healing
Cohen, Rodeo, AJSM 2006
Indomethacin & Celecoxib delay healing

Repair site histologically disorganised – Galatz,
2006
Repair tissue from epitenon of bursal surface –
Kazuyoshi, 2004
Better healing in immobilised repairs
Thomopoulos 2003
Uhthoff JBJS (Br) 2000
Gerber JBJS 1999

OVERALL HEALING RATES : 30-85%
Gerber JBJS, 2004 (Sheep studies)
Gladstone AJSM, 2007
Repair at 40 weeks
Approx 7 times decreased elasticity
Muscle atrophy, Fatty infiltration, increased
interstitial connective tissue – irreversible
changes despite healing
Atrophy & FI – adverse functional outcomes

Consider Biology First
Age
Tear Characteristics (muscle atrophy/FI)
Co morbidities
Smoking

Young patients with small tears
Limiting factors – Surgeon, construct, rehab &
smoking
NOT Biology
Older patients with large tears
Limiting Factor - Biology

Above 65 years – poor healing
pain relief – objective
single row
atrophy/FI – irreversible and will affect
outcome
Customise advice to patient

Young patients < 50 Yrs
better healing potential
double row/biology
good functional results
Yearly ultrasounds of minimally symptomatic
cuff tears - progression

Platelet Rich Plasma
Stem Cells
Collagen coated sutures
Vents in anchors/crimson duvet of Snyder

Effect of muscle load on cuff healing –
Galatz
Biofactors for normal enthesis
development - Thomopoulos

E-325 SECTOR 27, NOIDA
OPPOSITE MAX HOSPITAL, NOIDA

Natural History of Degenerative Cuff Tear-Decision Making-Dr A.N. Misra

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Natural History of Degenerative Cuff Tear-Decision Making-Dr A.N. Misra